Ofr-Com-101 - Registration Of Commercial Collection Agency (Page 2 of 2) in pdf

Has the prospective registrant, or any principal of same, engaged in any unlawful collection practices, or been convicted or

found guilty of a crime involving dishonest dealing, acts of moral turpitude, or other acts that reflect an inability to engage in the

commercial collection agency business?

YES ____ NO ____

10. Has the prospective registrant, or any principal of the same, or any business in which any principal of the prospective registrant

was the owner of 10 percent or more of such business had any professional or occupational license which was the subject of

any suspension, revocation, or other disciplinary action?

YES ____ NO ____

For each "Yes" response to Questions 9 & 10, provide details clearly identifying and explaining each occasion.

11. Provide a copy of a continuous surety bond in the amount of $50,000, issued by a bonding company or insurance company

authorized to do business in the State of Florida, with documentation that the annual premium has been paid in full by the

prospective registrant. Include a statement from the surety that the bond meets the requirements of Chapter 559, F.S. and a

copy of their current Florida Office of Insurance authorization.

12. Provide an alphabetical list of the following:

Each county in this State in which the applicant currently operates an office including the occupational license number for

that county.

Each county in this State in which the applicant plans to operate an office within the next calendar year.

Each county in this State in which the applicant is operating under a fictitious name or trade name including any such

fictitious or trade name and the date and place of registration of that name.

Any other corporations, entities, or trade names through which any owner or director of the applicant was known or did

business as a commercial or consumer collection agency within the last five (5) calendar years. (Provide one list for each

owner/director as applicable).

I hereby affirm that the foregoing information is true and correct and acknowledge that any misstatement may cause the Office to

initiate proceedings against the registration.

_____________________________________

_______________________________________

Name (Type or Print)

Signature of Principal in Business

(Must be principal in Business)

____________________________________

_______________________________________

Title (Type or Print)

Date

OFR-COM-101 Rev. 05-01-04

Ofr-Com-101 - Registration Of Commercial Collection Agency Page 2